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Device Problem
Adverse Event Without Identified Device or Use Problem (2993)
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Patient Problem
Bacterial Infection (1735)
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Event Date 12/16/2020 |
Event Type
Death
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Event Description
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Additional details for this patient: the patient was initially cannulated for ecmo for acute on chronic hypoxemic respiratory failure related to her copd and idiopathic pulmonary fibrosis.The patient was found to have positive blood and sputum cultures for burkholderia.The patient continued to deteriorate despite maximal cardiopulmonary support and expired.Manufacturer response for heater/cooler, (brand not provided) (per site reporter) no response to date.
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Event Description
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The infection control service noted an increase in burkholderia infections amongst patients on the cardiothoracic icu.Isolates were sent for genome sequence testing.Six of the patients had closely related sequences and a seventh had a potentially related sequence.All the patients were reviewed.A common trait amongst all was the use of ecmo for cardiopulmonary support.The ecmo devices were investigated.Ecmo devices have a pump component and a heater component.The heater is needed to maintain body temperature while the blood is outside the body.The heater has a water bath.The water in the bath is not in contact with blood from the patients but is present inside the patient's room.Water baths were cultured and found to have burkholderia.Some water baths also had a second organism called cupriavidus pauculus.All ecmo heater devices were taken out of service.The culture results suggest the source of the patients' infection may be the water heaters.Additional details for this patient: the patient was initially cannulated for ecmo for acute on chronic hypoxemic respiratory failure related to her copd and idiopathic pulmonary fibrosis.The patient was found to have positive blood and sputum cultures for burkholderia.The patient continued to deteriorate despite maximal cardiopulmonary support and expired.Manufacturer response for heater/cooler, (brand not provided) (per site reporter) no response to date.
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